UNI-02 Plan of Care waiver revised...

SDS SUPPORT PLAN (SP) COVER SHEET

Completed by Care Coordinator:

Recipient Name:

CC Name:

CC Agency Name:

SP Type: ☐ ALI - Alaskans Living Independently

☐ APDD - Adults with Physical and Developmental Disabilities

☐ CCMC - Children with Complex Medical Conditions

☐ IDD - Individuals with Intellectual and Developmental Disabilities

☐ ISW - Individualized Supports Waiver

☐ CFC - Community First Choice

☐ Grant

New ☐ Renewal ☐

If Renewal: No Service Change ☐ Provider Change Only ☐

LOC Start Date LOC End Date

SP Start Date SP End Date

Date Stamp Here:

State of Alaska • Department of Health and Social Service • Division of Senior and Disabilities Services Support Plan (SP)

Legal Name (Last, First):

DSDS ID#: SP Start Date: SP End Date:

Section I ~ Demographic InformationMedicaid#: DOB:

Male ☐ Female☐ Married ☐ Single ☐ Height: Weight:

Ethnicity:

Primary Language:

If non-verbal, primary mode of communication:

If a communication barrier exists, please provide an English speaking contact for scheduling:

Contact name: Contact Phone: Relationship:

Recipient’s Physical Address or directions to home in rural areas (No P.O. Boxes):Address:

City: State: Zip:

Work-Phone: Home-Phone: Cell-Phone:Email:

Mailing address (if different than physical):Address:

City: State: Zip:

Recipient’s Legal Representative:Does the recipient want SDS documents mailed to the Power of Attorney (POA)? Yes ☐ No ☐Name: Role/Relationship:

Mailing Address:City: State: Zip:

Work-Phone: Home-Phone: Cell-Phone: E-Mail:

Recipient’s Emergency Contact:Name: Relationship:

Address: City: State: Zip:

Work-Phone: Home-Phone: Cell-Phone:Email:

School (If Applicable):School Name: Contact Name: Phone:

Address: City: State: Zip:

Employment (If Applicable:)

UNI-02 (Rev 10.15.18) All Waivers and CFC PCS Support Plan of 18




Place of Employment: Contact Name: Phone:Address: City: State: Zip:

Care Coordinator: Name: Cell-Phone: Email:

Agency: Work-Phone: Fax#:

Address:City: State: Zip:

CM#: CMG#:

Section II ~ Diagnosis & MedicalPrimary Diagnosis including ICD code from the Verification of Diagnosis (VOD) or the Qualifying Diagnosis Certification (QDC):

Secondary Diagnosis(es) including ICD code from the VOD or QDC:

Source(s) for diagnostic information (including the medical professional from the VOD or QDC):

Health Summary:

Summarize the health history over the past 12 months: Ensure the health synopsis contains current information/narrative related to the person’s health condition and needs.

Current information examples: Doctor’s appointments, expected or unexpected health events, critical incidents, and/or improvements in health from the past year, emergency room visits, hospitalizations, surgeries or treatments. If applicable include description of scheduled or anticipated surgeries and/or treatments. Include information on scheduled health appointments and procedures from last year. Provide information about health even if there was no significant change in health. Quote the recipient’s own concerns and viewpoints on his/her health if applicable.

Summary:

Medical and/or Psychiatric Contacts: (Highlight, right-click & insert additional rows as needed)Include a fax number for a primary physician as well as a contact phone number for all providers listed.





Full Name Address Phone & Fax Reason for visits and frequency

Current Medications: (Highlight, right-click & insert additional rows as needed)

Medication Dosage Prescriber Reason Prescribed Administered how?





Adaptive Medical Equipment (DME/SME) : List all adaptive medical equipment currently in use/available to the applicant regardless of funding source: ☐ Bath Bench ☐ Gait Belt ☐ Lift/Hoyer ☐ Braces/AFOs ☐ Grab Bars ☐ Stair Glide ☐ Cane ☐ Hand Held Shower ☐ Wheelchair ☐ Commode ☐ Elevated Toilet

☐ Hospital Bed ☐ P.E.R.S/Lifeline

☐ Walker

☐ Other:

List adaptive medical equipment needed:

Environmental Modifications (EMODs)List all environmental modifications completed for this recipient regardless of funding source:

List environmental modifications needed:





Emergency Response and Back Up System:

It is the recipient’s responsibility to have a contingency plan.

I reside in a licensed residential living facility which has an emergency plan ☐ Yes ☐ No

I have discussed my personal emergency plan with my care coordinator. ☐ Yes ☐ NoProvide emergency response and backup system information. For example if using an Assisted Living home, refer to the emergency and evacuation plan in place through this service. If agency emergency plan is provided, explain how this plan will ensure the recipient’s health and safety.

Examples: Indicate safety resources closest to the recipient, how the recipient will access these resources, and how these resources will know how best to assist the recipient.

If there are no services that provide an emergency plan, for example: people who live alone or with family/friends: Share resources with the person about emergency response in the person’s community, such as Red Cross and

local emergency shelters and evacuation procedures. Document how the recipient was assisted to understand and establish their own emergency response in the event

of a natural disaster or other emergency. Indicate how this plan will adequately meet the needs of the recipient with specific regard to their living

environment and physical ability to self-assist. Include the person’s concerns for his/her own safety and level of risk.

Emergency response plan:





SECTION III. ~ Personal Profile

Recipient’s Personal Goal: The individualized service-planning process offers the recipient the opportunity to identify personal goal(s). Recipients request services to meet their identified needs, and achieve expected outcomes. Explain how the recipient prefers those services to be delivered. Include specific reference to functional abilities and needs for support as found in the assessments you identify below.

Include in the summary the recipient’s: Overall life situation, home environment & relationships Progress toward previous goals Desirable future outcomes Social environment: friends, hobbies, favorite activities, places, spiritual/cultural preferences, etc Functional abilities and strengths Situational limitations, and/or obstacles What works and does not work when providing direct support Critical behaviors if applicable. If so, what are their interventions? Any additional information that could impact the level, or type, of requested service(s)

Summary:

Assessments Reviewed : List all assessments completed and reviewed in this planning process and include the source :





Section IV ~ Summary of Non-Waiver Supports and Services

List all other services currently utilized by the recipient; regardless of funding source. Examples include but are not limited to: PCA, other regular Medicaid services, community/social programs, and family supports. The Support Plan is an all-inclusive description of the recipient’s life.

Does this recipient receive General Relief (GR) funds? ☐ Yes ☐ No

Natural/Family Supports:(Highlight, right-click & insert additional rows as needed) Service Provider of Service Specific Service Frequency

(Minimum of weekly avg.)Total Service Duration

(State exact # of weeks)

Description of service that will meet recipient needs identified in Section III:

Community Supports:(Highlight, right-click & insert additional rows as needed)Service Provider of Service Specific Service Frequency

(Minimum of weekly avg.)Total Service Duration



Personal Care Services (PCS): (Highlight, right-click & insert additional rows as needed)PCS Type

(Agency-Based or Consumer Direct)

PCS Agency Specific Service Frequency(Minimum of weekly avg.)

Date of last Assessment


Does the PCS plan contain instrumental activities of daily living (IADL)? ☐ Yes ☐ No

Do any PCS providers reside with the recipient? ☐ Yes ☐ No

Are any of the PCS providers related to the recipient? ☐ Yes ☐ NoIf yes, identify by name & describe relationship:Community First Choice (CFC) Services:





CFC Service

Agency Specific Service Frequency(Minimum of weekly avg.)

Total Service Duration(state exact # of weeks)

CFC-PCS Type (Agency-Based or Consumer-Directed)

Skills Acquisition/ Training

(3% of Weekly PCS hours)

(Limit of 12 weeks )

PERS Installation

PERS Ongoing (up to 12 months/year)


Does the CFC-PCS plan contain instrumental activities of daily living (IADL)? ☐ Yes ☐ No

Do any CFC-PCS providers reside with the recipient? ☐ Yes ☐ No

Are any of the CFC-PCS providers related to the recipient? ☐ Yes ☐ NoIf yes, identify by name & describe relationship:

Regular Medicaid: (Highlight, right-click & insert additional rows as needed) Service Provider Agency Specific Service Frequency

(Minimum of weekly hourly avg.)Total Service Duration



Other Supports: (Highlight, right-click & insert additional rows as needed)Service Provider of Service Specific Service Frequency

(Minimum of weekly hourly avg.)Total Service Duration







Section IV-A ~ Summary of Non-Habilitative Waiver Services (Copy & paste additional blank service blocks as needed for each service requested and each service provider)

List and fully describe all non-habilitation services. NOTE: These services should clearly and concisely communicate the strengths, needs, desires and plans for the recipient in such a manner that a provider could pick up the document and use it as a working tool to provide uninterrupted services.

Non-Habilitative Service: Service Provider Agency &

Contact Phone#Specific Service Frequency

(Minimum of weekly unit average)Total Service Duration

(Exact # of weeks or date range)

Description/justification of service that will meet recipient needs identified in Section III: Expected outcome(s):

Do any providers for this service reside with the recipient? ☐ Yes ☐ NoAre any of the providers for this service related to the recipient? ☐ Yes ☐ No

If yes to either question, identify by name & describe relationship:

Non-Habilitative Service:Service Provider Agency &

Contact Phone#Specific Service Frequency

(Minimum of weekly unit average)Total Service Duration

(Exact # of weeks or date range)

Description/justification of service that will meet recipient needs identified in Section III: Expected outcome(s):

Do any providers for this service reside with the recipient? ☐ Yes ☐ NoAre any of the providers for this service related to the recipient? ☐ Yes ☐ No

If yes to either question, identify by name & describe relationship:





Section IV-B ~ Summary of Habilitative Waiver Services (with Goals & Objectives)(Copy & paste additional blank service blocks as needed for each service requested and each service provider)

List and fully describe the services that will be provided to meet the needs of the individual as identified in Section III. The habilitative services provided along with the corresponding skill development should be linked to the needs identified in the profile and assessments. Home and Community Based (HCB) Waiver and Grant Funded habilitative services require specific learning or habilitation skills that are addressed through the goals and objectives in this section. Goals should have distinct methodology/procedures described, including parties responsible for implementation. One goal may be implemented across other services to assure continuity of services. The objectives must be measurable. Data collected, and how objectives will be measured, must be clearly described and made available for review upon request.NOTE: These services should clearly and concisely communicate the strengths, needs, desires and plans for the recipient in such a manner that a provider could pick up the document and use it as a working tool to provide uninterrupted services.

Refer to the definition of habilitative services when writing narrative: Habilitative services support the person to acquire, build or retain skills in the following areas, including but not limited to: Mobility/Motor skills, Self care/ Personal Living, Communication, Learning, Self direction/Social skills, Living skills/ Community Living, Economic self-sufficiency/ Vocational skills. Habilitative services support self-help, socialization and adaptive skills aimed at raising the level of physical, mental, and social functioning of an individual.Habilitative Service #1

Service Provider Agency & Contact Phone#

Specific Service Frequency(Minimum of weekly unit average)

Total Service Duration(State exact # of weeks)

Description/justification of service that will meet recipient needs identified in Section III:

Do any providers for the service listed reside with the recipient? ☐Yes ☐ No

Are any of the providers for this service related to the recipient? ☐Yes ☐ NoIf yes to either question, identify by name & describe:

I. Goal (habilitative services) related to this service:

Is this goal: ☐ New ☐ Revised ☐ Continued

List objectives (steps of skill development or maintenance) which the person will use to reach the goal above

a) List methodology/intervention for each objective. Indicate how supports will teach the skill(s).

b) Indicate how data will be recorded and measured for each objective.

c) Indicate how the objective(s) will be reviewed and evaluated, including frequency and duration of evaluation.

What position(s) within the agency will be responsible for providing the supports for the above objectives? Habilitative Service #2





Service Provider Agency & Contact Phone#

Specific Service Frequency(Minimum of weekly unit average)

Total Service Duration(State exact # of weeks)

Description/justification of service that will meet recipient needs identified in Section III:

Do any providers for the service listed reside with the recipient? ☐ Yes ☐ No

Are any of the providers for this service related to the recipient? ☐ Yes ☐ NoIf yes to either question, identify by name & describe:

I. Goal (habilitative services) related to this service:

Is this goal: ☐ New ☐ Revised ☐ Continued

List objectives (steps of skill development or maintenance) which the person will use to reach the goal above

a) List methodology/intervention for each objective. Indicate how supports will teach the skill(s).

b) Indicate how data will be recorded and measured for each objective.

c) Indicate how the objective(s) will be reviewed and evaluated, including frequency and duration of evaluation.

What position(s) within the agency will be responsible for providing the supports for the above objectives?

☐ Providing agency certifies that the group home site is not requesting separate reimbursement for day habilitation service or any service provided by another resident of the group home.

☐ Providing family home habilitation site is not requesting reimbursement for any other waiver services.

☐ Providing agency certifies that the services of in home support habilitation or supported living habilitation are provided on a one to one basis.

☐ Providing in home support agency is not requesting reimbursement for any other waiver service provided by another resident of the home or by the primary unpaid caregiver.





Section V ~ Out-of-Home Residential Services Any recipient receiving waiver or grant funded out-of-home residential services (including residential supported living, group home, or family habilitation) must complete this section. The description of services and expected outcomes must be based on the recipient’s needs identified in Section III.

Name of residential facility or family habilitation provider:Administrator: Cell-Phone:Office-Phone: Fax#:Email:Physical Address:

City: State: Zip:

Admission Date:

Description of staffing pattern, including how live-in and shift staff are scheduled:

Is this a state licensed home and is the license current as of the SP Start Date? ☐ Yes ☐ No Does this recipient’s placement meet regulatory requirements for this licensed home? ☐ Yes ☐ No (i.e.: maximum number of persons in home, receiving care, child versus adult license, waiver type eligible for this service etc.)

Need Service Provided by Residential Provider Include frequency & duration

Expected Outcome(If item covered in goal/objective, indicate)

Nutrition, Eating, Feeding

Bathing/Hygiene, GroomingToileting/Incontinence

Skin Care

Dressing

Mental Status, orientation, memory, behaviorsMedication Management/Supervision/AssistanceLaundry/Chores

Mobility/Ambulation,SafetySocialization

Other Needs (e.g.: weight, vital signs, treatments, skin/wound care, etc.)Other Needs (e.g.: monitor seizure activity, chest pain, etc.)Transportation/Medical AppointmentsCommunication with other caregivers





Section VI ~ Planning Team

List all members of the planning team. The planning team must include the recipient, the recipient’s legal representative if applicable, the certified Care Coordinator, and representative of each certified provider that is expected to provide services, excluding transportation, environmental modification and specialized medical equipment providers (per 7 AAC 130.217). Each planning team member must sign the Support Plan.

Name Role/ Agency Phone Consulted byIn-person email phone videoconference

Recipient

Legal Representative

Care Coordinator

Natural Support

NOCM Nurse(if applicable)

HCB Agency Name:

HCB Agency Name:

HCB Agency Name:

HCB Agency Name:

HCB Agency Name:

HCB Agency Name:

CFC PCS Agency Name(if applicable)

Tribal Health Organization (if applicable)





Section VII ~ Grant Funded Agreement

To be completed if this Plan of Care is for GRANT FUNDED SERVICES ONLY. All others continue to Section VIII, Recipient Choice of Service.

This Individualized Support Plan has been carefully planned and coordinated with the active involvement of the recipient served. Necessary personnel and the recipient served will be involved in the evaluation of this plan’s continuing appropriateness.

I, or any member of my team, may request another meeting at any time during the next 12 months to make changes to this plan. Unless otherwise stated, I am in agreement with this Support Plan as written.

Recipient Signature Date Parent or Legal Representative Date

Care Coordinator Date DD Grantee Agency Representative Date





Sect

ion VIII ~ Recipient Choice of Service: To be completed by Waiver Recipient. Please read, check each statement indicating understanding, and select your service choice.

Having a completed or approved Support Plan does not guarantee eligibility for Medicaid Services. HCB Waiver and CFC PCS recipients must continue to meet annual financial eligibility requirements established by the Division of Public Assistance. In addition, certified and enrolled providers must be available to provide services.

I understand that:___This is an application process to find out if Medicaid will pay the cost of my long-term care services.

___If I am found eligible, and if services are available to me in my community, I may choose to receive:The services described in this Support Plan, OR Care in an institutional facility, ORCommunity services only, ORNo Medicaid or community services at all.

___If I choose to receive institutional care, my care coordinator will help me select a facility to meet my needs.

___If I chose to receive Medicaid Home and Community Based Waiver or Community First Choice Personal Care services, my care coordinator has given me a brochure describing what these services are.

___If I chose to receive Medicaid Home and Community Based Waiver or Community First Choice Personal Care services, my care coordinator has given me a list of certified providers in my community that I may choose to deliver my services.

___If I choose to receive Medicaid Home and Community Based Waiver or Community First Choice Personal Care services, the Division of Senior & Disabilities Services staff will review my case annually to see if I meet the Level of Care eligibility requirements. They will also evaluate the services requested in my Support Plan each year to be sure they are appropriate to meet my needs.

___ If I choose to have no Medicaid Home and Community Based Waiver services, but do want to have Community services that are available where I live, my care coordinator, DSDS grantee agency, or DSDS staff will assist me to find participating agencies.

___I have the right to consult with whomever I choose before making this decision, including friends, relatives, and advocacy organizations, and that I may authorize any of these people to contact the care coordinator or DSDS staff to provide information in helping me make this decision.

___ If I choose Medicaid Home and Community Based Waiver or Community First Choice Personal Care services, but I am denied services, I may still be eligible for care in an institutional facility.

I choose to receive (Check only one):☐ Medicaid Home and Community Based Waiver or CFC Personal Care Services

☐ Services in an institution or nursing facility

☐ Non-Medicaid Waiver Community services only

☐ No Medicaid or community servicesUNI-02 (Rev 10.15.18) All Waivers and CFC PCS Support Plan of 18




Section IX ~ Signatures:This individualized Support Plan has been carefully planned and coordinated with the active involvement of the recipient served. It has been explained that the intended purpose of this plan is to help the recipient maximize his/her independence and lead a fulfilling life. Necessary personnel, and the recipient served, will be involved in the evaluation of this plan’s continuing appropriateness. It has been explained that each member of the planning team will receive, or have access to, a copy of the final Support Plan.

By signing below, I certify that the information included in this Support Plan is true and accurate to the best of my knowledge. I have been informed of any familial or business relationship between the care coordinator and any HCB provider.

Recipient Signature Date Parent or Legal Representative Date

Care Coordinator Date Other Natural Support Date

NOCM Nurse (if applicable) Date Printed Name Agency Name

HCB Agency Representative Date Printed Name Agency Name





CFC PCS Agency Representative Date Printed Name Agency Name

Tribal Case Manager Date Printed Name Tribal Health Organization (if applicable) Two witnesses are required if recipient signs with an X or a stamp. The Care Coordinator may not serve as a witness.

Witness Printed Name Signature Relationship Date

Witness Printed Name Signature Relationship DateSTATE OF ALASKA USE ONLYThis plan has been processed for prior authorization.





DSDS Representative Position Date


UNI-02 Plan of Care waiver revised...

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